A 33-year-old G2P2 woman presented at the outpatient clinic complaining of intermenstrual spotting. She had her first menstrual cycle 17 years ago. Her menstrual cycle length is 28 days and menstruation lasts for five days. Her last cycle was two weeks ago. The menstrual volume is normal and she did not notice any change over the last years. The patient delivered two healthy baby girls through two cesarean sections based on her preference. She had her last cesarean section six months ago. Her medical history is unremarkable. She denies the use of any contraceptive pills. The patient mentioned that she is not considering having more children.
- Uterine niche
- Endometrial polyp
- Endometrial hyperplasia
- Normal endometrial strip
- No endometrial polyps
- No uterine fibroids
- 3×4 uterine niche was found.
- Residual myometrial length measured 3.5 mm
Repeated transvaginal ultrasonography scan with intrauterine saline injection (hydrosonography) confirmed the previous findings.
- Laparoscopic niche resection
- Hysteroscopic niche resection
- Niche resection through vaginal approach
- Expectant management.
Hysteroscopic niche resection.
Uterine niche, or cesarean scar defect, is defined as an indentation in the myometrium of at least 2 mm on the side of the uterine cesarean scar. It develops due to abnormal healing of the anterior uterine wall at the level of the inferior uterine segment following one or more cesarean sections.
The exact cause of this pathology is not known yet. However, it was found in 60% of women that had a previous cesarean section after 2-12 weeks. The occurrence of uterine niche after three cesarean sections increases to 100%.
The uterine niche is usually asymptomatic, but it could also cause intermenstrual spotting, pelvic pain, or infertility. Spotting is thought to be caused by the accumulation of the menstrual blood in the niche. The uterine niche could be visualized through transvaginal ultrasonography and magnetic resonance imaging. The optimal treatment of the uterine niche is controversial. Nonetheless, it heavily depends on the patient’s case. Asymptomatic niches could be left untreated. Laparoscopic niche resection is suggested to be the optimal choice for patients desiring further fertility or with a residual myometrial length of less than 3 mm. This approach restores the normal uterine anatomy.
On the other hand, hysteroscopic niche resection is basically widening the niche through resecting the distal border of the niche, which prevents the accumulation of the menstrual blood and resolves the spotting. This approach is preferred in patients whom the residual myometrial length measures 3 mm or more
1) Klein Meuleman SJM, Verberkt C, Bouwsma EVA, Huirne JAF. Regarding “Reproductive Outcomes Following Surgical Management for Isthmoceles: A Systematic Review”. Journal of Minimally Invasive Gynecology. 2021 Oct;28(10):1800
2) Jordans IP, De Leeuw RA, Stegwee SI, Amso NN, Barri‐Soldevila PN, Van Den Bosch T, Bourne T, Brölmann HA, Donnez O, Dueholm M, Hehenkamp WJ. Sonographic examination of uterine niche in non‐pregnant women: a modified Delphi procedure. Ultrasound in Obstetrics & Gynecology. 2019 Jan;53(1):107-15.
3) Bij de Vaate AJ, Brölmann HA, Van Der Voet LF, Van Der Slikke JW, Veersema S, Huirne JA. Ultrasound evaluation of the Cesarean scar: relation between a niche and postmenstrual spotting. Ultrasound in obstetrics & gynecology. 2011 Jan;37(1):93-9.
4) Van der Voet LF, Vervoort AJ, Veersema S, BijdeVaate AJ, Brölmann HA, Huirne JA. Minimally invasive therapy for gynaecological symptoms related to a niche in the caesarean scar: a systematic review. BJOG: An International Journal of Obstetrics & Gynaecology. 2014 Jan;121(2):145-56.